HospitalInspections.org

.
Based on interview and document review, the hospital Case Management staff failed to follow hospital policy and procedures that required staff to provide patients with a list of local post discharge services/agencies for 9 of 11 patient records reviewed (Patient #1101, #1102, #1103, #1106, #1107, #1108, #1109, #1110, #1111).

Failure to follow policies and procedures designed to ensure full disclosure of post hospital options for services/agencies available locally puts patients at risk for inappropriate or unsafe discharge from the hospital.

Findings included:
.
1. Document review of the hospital policy, "Discharge/Transition Planning 61.14," PolicyStatID: 8403928 Effective date 08/2020, showed that the Freedom of Choice list is given to any patient discharging to a skilled nursing facility or home health care.
.
Document review of hospital policy, "Patient Freedom of Choice, 1503.05," PolicyStatID: 8781330 Effective date 10/2020, showed that patients have the right to be informed and participate in choice regarding after hospital service providers without undue influence.
.
Document review of hospital policy, "Home Health Referral, 604.00.00," PolicyStatID: 7645240 Effective date 02/2020, states that the "Choice Discharge Resource Options form #1488" is to be provided to the patient. Staff are to obtain signature of preference. Documentation is to be put in the patient record.

2. Document review of the hospital's form titled, "Choice Discharge Resource Options," Form #1488 dated 10/15, also known as the Freedom of Choice list, showed that there were multiple options for post discharge agencies within the community. There is also an area to check next to each option and a line for patient signature and date at the bottom of the page.

3. On 10/27/20 at 9:00 AM, the investigator interviewed 5 patients about discharge plans and options post-discharge. 3 of 5 patients, (#1101, #1102, #1103) had not received information about the various home health agencies within the community.

4. Record review of 7 current patient medical records and 4 discharged patient medical records showed:

a. 5 of 7 current patient medical records, (Patient #1101, #1102, #1103, #1106, #1107) showed no evidence that a list of home health agencies, skilled nursing facilities or hospice agencies were given to the patients for review and selection prior to discharge.

b. 4 of 4 discharged patients medical records , (Patient #1108, #1109, #1110, #1111), showed no evidence that a list of home health agencies, skilled nursing facilities or hospice agencies were given to the patients for review and selection prior to discharge.

5. On 10/27/20 at 9:30 AM, the investigator interviewed case manager (Staff #1101). The interviewed showed that Staff #1101 was not aware that the Freedom of Choice form was supposed to be signed by the patient and placed in the medical record.

6. On 10/28/20 at 10:19 AM, the investigator interviewed Clinical Resource Management Manager, (Staff #1111) and Coordinator of Clinical Resource Management, (Staff #1112). Interview showed that neither was aware that the Freedom of Choice document was required to be signed and planced in the patient chart. Staff #1111 reviiewed the policy titled, "Home Health Referral, 604.00.00," PolicyStatID: 7645240 Effective date 02/2020 reviewed and verified that signature is required and documentation is to be placed in the patient's medical record.

.